Pharmacy Prior Authorization Criteria

Auvelity (dextromethorphan hydrobromide / bupropion hydrochloride) - PA, ST

Indications for Prior Authorization

Auvelity (dextromethorphan hydrobromide / bupropion hydrochloride)

• For diagnosis of Major Depressive Disorder
  Indicated for the treatment of major depressive disorder (MDD) in adults.

• For diagnosis of Agitation with Dementia Due to Alzheimer's Disease
  Indicated for the treatment of agitation associated with dementia due to Alzheimer’s disease.

  Limitations of Use: Auvelity is not indicated as an as needed (“prn”) treatment for agitation associated with dementia due to Alzheimer’s disease.

Criteria

Auvelity

Step Therapy

Length of Approval: When approved; no reauthorization required
For diagnosis of Major Depressive Disorder

• Both of the following:
• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to any two of the following generics:
• bupropion
• citalopram
• desvenlafaxine extended-release (ER)
• duloxetine
• escitalopram
• fluoxetine
• mirtazepine
• paroxetine IR/ER
• sertraline
• venlafaxine IR/ER
OR
• For continuation of prior therapy

Auvelity, Auvelity Titration Pack

Prior Authorization

Length of Approval: 12 Month(s)
For diagnosis of Agitation with Dementia Due to Alzheimer's Disease

• Diagnosis of Alzheimer's disease
AND
• Requested medication is used for the treatment of agitation (e.g., behavioral disturbance, aggression, or psychomotor agitation) associated with dementia due to Alzheimer’s disease
AND
• Auvelity will not be used on an as needed basis for the treatment of agitation associated with dementia due to Alzheimer’s disease
AND
• Prescribed by or in consultation with one of the following:
• neurologist
• geriatrician
• psychiatrist

P & T Revisions

2026-06-25, 2026-06-04

References

1. Auvelity Prescribing Information. Axsome Therapeutics, Inc. New York, NY. June 2026.
2. Alzheimer’s Association: Criteria for Diagnosis and Staging of Alzheimer’s Disease. Available at: https://www.alz.org/research/for_researchers/diagnostic-criteria-guidelines. Accessed May 13, 2026.
3. Jack Jr, Clifford, Andrews, J Scott, Beach, T., et al. Revised criteria for diagnosis and staging of Alzheimer’s disease: Alzheimer’s Association Workgroup. Available at: https://alz-journals.onlinelibrary.wiley.com/doi/epdf/10.1002/alz.13859. Accessed May 13, 2026.
4. Bui, Q. Antidepressants for Agitation and Psychosis in Patients with Dementia. Available at: https://www.aafp.org/pubs/afp/issues/2012/0101/p20.html. Accessed May 13, 2026.
5. Chen, K., Li, H., Yang, L., et al. Comparative efficacy and safety of antidepressant therapy for the agitation of dementia: A systematic review and network meta-analysis. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10020338/. Accessed May 13, 2026.
6. Patino, E. Medications to Manage Alzheimer’s Agitation. Available at: https://resources.healthgrades.com/right-care/alzheimers-disease/medications-to-manage-alzheimers-agitation?did=t9_ggl1&utm_source=google&utm_medium=cpc&utm_cmpid=23755134617&utm_lineid=195092513723&utm_adid=791804043319&utm_network=g&utm_device=c&utm_gclid=EAIaIQobChMItdmIgeO2lAMVdk7_AR05TiAOEAAYBCAAEgIP3vD_BwE&gad_source=1&gad_campaignid=23755134617&gbraid=0AAAAAD0nnzUXKjkuU2NHgUkhg7OKXTOmM&gclid=EAIaIQobChMItdmIgeO2lAMVdk7_AR05TiAOEAAYBCAAEgIP3vD_BwE. Accessed May 13, 2026.
7. Grossberg, G., Sanford, A., Montano, C., et al. A US-based practitioner’s guide to diagnosis, evaluation, and evidence-based treatment of agitation in Alzheimer’s dementia – recommendations of an expert, multispecialty advisory panel. Available at: https://www.tandfonline.com/doi/full/10.1080/00325481.2025.2517535?src=recsys. Accessed May 13, 2026.
8. El-Hussein,M and Kana, E. Management of Agitation in Dementia: Pharmacological Considerations for Nurse Practitioners. Available at: https://www.npjournal.org/article/S1555-4155(26)00127-3/fulltext. Accessed May 13, 2026.
9. McDermott, C., and Gruenewald, D. Pharmacologic Management of Agitation in Patients with Dementia. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6653648/. Accessed May 13, 2026.
10. American Academy of Physician Associates. Pharmacologic Approaches in the Management of Neuropsychiatric Symptoms (NPS) in Alzheimer’s Disease (AD). Available at: https://www.aapa.org/education/clinical-resource-library/nps-toolkit/pharmacologic-approaches-in-the-management-of-neuropsychiatric-symptoms-nps-in-alzheimers-disease-ad/. Accessed May 13, 2026
11. Reus, V., Fochtmann, L., Eyler, E., et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. Available at: https://psychiatryonline.org/doi/10.1176/appi.ajp.2015.173501. Accessed May 13, 2026.
12. American Psychiatric Association. Antipsychotic Medications to Treat Agitation or Psychosis in Adults with Dementia. Available at: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Dementia-Patient-and-Caregiver-Guide.pdf. Accessed May 13, 2026.
13. American Psychological Association. APA Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change. Available at: https://www.apa.org/practice/guidelines/guidelines-dementia-age-related-cognitive-change.pdf. Accessed May 13, 2026.
14. Teixeira, A., Kim, Y., Cordeiro, T., et al. Agitation in Alzheimer’s disease: From assessment to therapeutics. Available at: Agitation in Alzheimer’s disease: From assessment to therapeutics - PMC. Accessed May 13, 2026.
15. [Antidepressants]. In: IBM Micromedex DRUGDEX. IBM Watson Health. https://www.micromedexsolutions.com Accessed May 13, 2026.
16. [Antipsychotics]. In: IBM Micromedex DRUGDEX. IBM Watson Health. https://www.micromedexsolutions.com Accessed May 13, 2026.

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Revision History

• 2026-06-25: update guideline
• 2026-06-04: update guideline

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